When the heart and lungs of Resident 11 stopped working, no one at the nursing home Dexter Health Care attempted revival with CPR.
State and federal regulations, however, say CPR should have been attempted. The death led to the largest state fine against a nursing home in Maine in 2013.
Across the nation, there have been dozens of cases recently documented in which nursing home staff failed to give CPR to those who needed and wanted it.
This time it happened in Maine, even though the state statistically performs better than most others.
“It’s a serious problem,” said Toby Edelman, senior policy attorney with the Center for Medicare Advocacy, a national organization based in Willimantic, Conn.
Edelman, who has devoted much of her 40-year career to improving nursing home conditions around the country, said the number of serious abuses documented in nursing homes is always just a small fraction of the abuses that are actually occurring.
Only six states have fewer serious documented deficiencies per nursing home than Maine. In Kentucky, with the worst ratio in the nation, there were 1.35 serious deficiencies per nursing home over the past three years, 22 times Maine’s average of 0.06.
Maine may do a good job, but when it comes to caring for a vulnerable population like the state’s elderly, a good job may not be good enough, she said. Edelman said advocacy groups are pushing for more improvements, for the sake of Resident 11 and thousands of other nursing home residents across the nation.
Resident 11 lived at Dexter Health Care, a 53-bed, for-profit nursing home in Dexter, a former mill town of fewer than 4,000 people halfway between Waterville and Bangor on the banks of the Sebasticook River. Resident 11′s personal information — name, health problems, age, even gender — were not published in the inspection report, but one important detail is included.
In the event of an emergency — if Resident 11′s heart stopped beating and lungs stopped breathing — Resident 11 wanted staff to attempt revival with cardiopulmonary resuscitation, or CPR.
But when that moment came, no one attempted to administer CPR to Resident 11.
After Resident 11′s death, Dexter Health Care was fined $5,850, the second largest such fine in the state in at least three years, for violating federal law that prohibits the mistreatment, neglect or abuse of nursing home patients.
In a statement given Friday, the nursing home’s health management team did not admit fault in the case of Resident 11′s death and said instead that it disagreed with the state’s findings.
What happened in Dexter happens with surprising regularity at nursing homes across the nation. Every year, people in nursing homes who should have received CPR die without getting it, according to an analysis by ProPublica, a watchdog journalism group that provides a searchable database of nursing home deficiencies.
Over the past three years, there have been 161 inspection reports that have included serious deficiencies related to CPR. Some are for unrelated issues, but just a sampling of the records uncovered many instances in which people with clear directives to be revived by CPR have died without receiving it.
Such elder care issues are particularly pressing in Maine, which has more elders per capita than almost any other state.
It didn’t take long for the state to identify what happened in Dexter as a serious problem. An outline of the incident is given in the state’s four-page inspection report.
On July 2 at 2:11 a.m. at Dexter Health Care, a certified nursing assistant and at least one other staff member rolled Resident 11 over on a bed, an action that is part of many routine procedures, such as dressing or cleaning people who can’t do it themselves. The nursing assistant noticed that the resident’s arm stayed on the bed, something she had never seen before.
The nursing assistant asked if the resident was OK, she later told inspectors, and Resident 11 said yes.
Still, sensing that something was out of the ordinary, the assistant told the charge nurse that the resident’s right arm was “making a strange motion.”
Twelve minutes later, the charge nurse and the nursing assistant both went to the room, where they found Resident 11 unresponsive, with no pulse or other vital signs.
At this point, the charge nurse should have administered CPR, an instruction that was spelled out in the advance directives for that patient. A physician had signed an order Jan. 15, 2013, directing that CPR should be given to the patient. Furthermore, if a patient doesn’t have an advance directive, the default directive is to give CPR.
But she didn’t.
Resident 11 was declared dead, with no further efforts made to resuscitate.
Full code ignored
Not every patient in Resident 11′s position would choose to be revived with CPR.
Deciding how far one wants to go in extending one’s life in difficult circumstances can be an intensely personal decision, according to administrators at other area nursing homes.
Because many patients can’t communicate when the time for medical intervention comes, federal regulations require that every nursing home resident be given a chance to create a set of advance directives, written instructions used to guide health care decisions when a person is incapacitated.
Nursing homes routinely create advance directives for their patients, and review them every three months with patients and families to make sure they are up to date.
The directives are important, not just for nursing home residents, but for everyone, according to Carol Timberlake, administrator for both the Orchard Park and Edgewood rehabilitation and living centers in Farmington.
“If I can no longer speak for myself and I’m in a situation where there is no hope for me to regain my abilities, this is how I want to be managed,” Timberlake said. “Do I want to be given food or not? Do I want fluids or not?”
Another nursing home administrator, Carolyn Sawyer, said she understands why CPR is not always desirable.
“The chances of CPR working run low and it hurts,” she said.
She has seen it add unnecessary pain to the end of someone’s life at Somerset Rehabilitation and Living Center in Bingham and Heritage Rehab and Living Center in Winthrop, the two homes she oversees.
The right to fill out an advance directive is protected by federal law, according to John Martins, spokesman for the Maine Department of Health and Human Services, which oversees Maine’s nursing homes on behalf of the state.
Not every resident chooses to fill out an advance directive, but Resident 11 did, according to the state’s inspection report.
The advance directive of Resident 11 was clear.
In life-threatening situations, Resident 11 wanted to be taken to a hospital for treatment. Infections were to be treated with antibiotics.
Most importantly, if the resident’s heart stopped beating or lungs stopped breathing, the advance directive told staff that CPR should be used in an attempt at revival.
In January 2013, a doctor read and approved the advance directives, issuing Resident 11 a code status, which tells staff whether CPR should be given. Some patients are under a “do not resuscitate” order from a doctor, while others are full code, meaning they should be revived with CPR and other methods.
Resident 11 was given full code status.
A sampling of about 30 inspection reports from around the country show that many people, like Resident 11, have asked for CPR but died in a nursing home without it in recent years.
In 2013, for which only partial data has been published, similar cases resulted in deaths, not only in Dexter, but in Hornell Gardens in Hornell, N.Y., and Kenilworth Care and Rehabilitation Center in Florida, among others.
In another case, at Rockdale Resident and Rehabilitation Center in Texas in 2011, a resident requested CPR but when the time came, staff deferred to his wife, who told them not to attempt resuscitation.
In that same year, two residents at Parks Methodist Retirement Village In Odessa, Texas; two more at Woodley Manor Health and Rehabilitation in Montgomery, Ala.; and a woman at Andrus on Hudson in New York were all among those who died without receiving CPR, despite having full code status.
In 2012, similar cases resulted in deaths at Graceland Care Center of Oxford in Mississippi, Casa Morra Rehabilitation and Extended Care in Bradentown, Fla.; and Sunrise Care Center in Milwaukee, Wis.
A 2006 study from the Journal of the American Medical Directors Association found that 33 percent of nursing home residents who wanted CPR did not receive it prior to the arrival of emergency medical services.
In Maine, such elder care issues are increasingly important and will become more so in the years to come. Maine’s median age, 42.7 years, is highest in the nation, and it also has the third-highest percentage of people aged 65 or older, with 15.9 percent, according to the U.S. Census Bureau.
A first-in-the-nation 30.9 percent of Mainers are between 45 and 64 years old, which means that the next generation of those needing elder care will be even bigger.
With this in mind, a team of inspectors visits every nursing home in the state annually, or when a complaint or incident is reported. Within a week after Resident 11′s death, two complaints at Dexter Health Care prompted an inspection.
The inspectors are registered nurses, licensed social workers and health facility specialists who have all been certified to inspect long term care homes in the state. They are employees of the state, but inspect on behalf of both the state and federal governments.
Before Resident 11 died at Dexter Health Care, the home didn’t have a bad track record. During four previous state inspections, in 2011 and 2012, a handful of deficiencies, most of them minor and none resulting in fines, were found.
In its Friday statement, the Dexter nursing home touted its ratings, which include an excellence award from a national research company based on feedback ratings from patients and families.
But when the inspectors interviewed staff in July, the initial responses suggested that there was confusion, not just about Resident 11, but about the nursing home’s resuscitation policies in general.
In July, when inspectors asked the charge nurse why she didn’t attempt to revive Resident 11, she said she didn’t know the resident’s code status.
When they talked to the nursing director, the director said staff at Dexter Health Care weren’t required to give CPR unless the cardiac or respiratory failure was witnessed.
That drove the inspection team to look at Dexter Health Care’s policies, where they uncovered a second problem.
“The policy did not address what staff were to do in the event they discovered a unwitnessed cardiac or respiratory arrest on a resident with advanced directives indicating (the desire to have CPR),” according to the inspection report.
That means if a person’s heart or lungs failed while no one is in the room, then the staff didn’t have to give CPR when they discovered the body, even if the patient’s advance directives asked that they do so.
The state inspectors asked for more information. They checked a list of CPR-certified staff against payroll sheets and worker schedules.
That led to the discovery of a third problem.
They found that, just two days after Resident 11 died, seven other residents who also had asked to receive CPR in their advance directives were at risk of not getting it.
Why? Because no one that night at the nursing home was certified to administer CPR.
“The facility was unable to provide evidence of a system to ensure CPR trained staff were available 24 hours a day, seven days a week,” inspectors wrote. “The failure of the facility to have staff who were certified in CPR placed the residents with full code status at risk of potential harm or death.”
In response to information requests from the Morning Sentinel, Dexter Health Care’s management team issued a three-paragraph statement on the death of Resident 11 that expressed sympathy for the family, but admitted no fault.
“We can tell you that in similar situations we do not provide CPR and other lifesaving measures when doing so would be futile,” the statement reads. “While our hearts go out to the families in these types of situations, in any health care setting there will always be some circumstances when death is irreversible.”
The nursing home would not discuss Resident 11′s death or its policies any further.
But Edelman said that by not being prepared to follow the advance directives, Dexter failed to honor an agreement with its residents.
“If you have residents who want CPR and no one is qualified to do it, that’s a really serious problem,” Edelman said.
Edelman said enforcement of nursing homes can be too lax and that fines are assessed too infrequently to make much of a difference. She said federal laws only allow fines to be imposed when actual harm has occurred and that many inspectors wrongly classify serious cases as not having caused harm.
“If we read the statements of deficiency, would we agree that these are the only six with serious deficiencies?” she asked.
Most nursing homes would have responded to Resident 11′s death differently.
If a resident had a full code status and was discovered without vital signs, the resident would have been given CPR at their nursing homes in Farmington, Bingham and Winthrop, Sawyer and Timberlake said.
That’s not just good elder care, officials say. It’s also the law.
In their report, the inspectors found Dexter Health Care had violated federal public health regulations that require nursing homes to “develop and implement written policies and procedures that prohibit mistreatment, neglect and abuse of residents.”
The nursing home was also cited for violating another federal regulation, that it provide care for “the highest practicable, physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.”
Federal regulations also require that nursing homes have CPR-certified staff available at all times, a requirement both Timberlake and Sawyer said they comply with.
In Farmington, Orchard Park and Edgewood nurses all have up to date certification, Timberlake said.
She knows this because the date of certification of each of the two homes’ 70 staff members is tracked in a computerized system that lets administrators know when someone’s certification is nearly expired.
On a regular basis, “we bring someone from the outside in and provide training for all the folks,” Timberlake said.
Both Timberlake and Sawyer said they also encourage their certified nursing assistants to be CPR certified.
During their most recent inspections, the four nursing homes overseen by Timberlake and Sawyer had no, or minor, deficiencies.
As a group, Maine’s nursing homes have fewer serious deficiencies than most states in the country.
“I think Maine overall does a pretty good job, but then once in a while you hear about something that’s horrendous,” said Linda Weare, who works as the elder abuse manager at Maine’s Elder Abuse Institute.
Weare said that, while abuses do happen in nursing homes, the institute’s focus is on residential situations, where elders who suffer abuse are often isolated from help, sometimes by the design of their abusers.
“In a nursing home, there are more people around, so the chances of people finding out are greater,” she said.
The financial penalties for violations in Maine are also less severe than those of other states. According to an analysis of the data performed by ProPublica, Maine fined its nursing homes a total of about $55,000 over three years, with an average fine of about $6,100, far below the national average of $11,300. The highest fines in the nation are assessed in Tennessee, which saw more than $5.6 million in fines, with an average amount of $72,327.
Phyllis Powell, assistant director for the Medical Facilities Unit at the state’s nursing home administrators licensing board, said it is rare for a nursing home to actually lose its license.
In fact, in the six years she’s been working in the department, she said, it hasn’t happened once.
Instead, documented deficiencies are handled with an eye toward bringing the offending business into compliance.
“If they are found in violation they have an opportunity to remedy that,” she said.
Chance at life
Would CPR have made a difference in the case of Resident 11? There’s no way to know.
CPR doesn’t guarantee survival, but it does have a chance of success. The idea is to use chest compressions and, sometimes, forced breaths into the lungs to keep oxygen-bearing blood moving through the body and into the brain until the heart can be restarted, often with a defibrillator. A 2009 study of nearly half a million patients published in the New England Journal of Medicine found that 18 percent of those who received CPR while in the hospital survived long enough to be discharged.
The 2006 study from the Journal of the American Medical Directors Association found survival rates for nursing home residents were lower, between 2 and 11 percent.
What’s often critical is how quickly CPR is administered.
In the event of cardiac arrest, the chances of survival decrease by 5 to 10 percent for every minute that CPR is not administered, according to the Centers for Disease Control.
Without a supply of oxygen, brain damage can happen in just a few minutes, and a person can die in eight to 10 minutes, according to the Mayo Clinic.
In this case, Resident 11 was alive and answering questions 12 minutes before the charge nurse entered the room and found no pulse or other vital signs.
Dexter Health Care’s statement said the state inspectors were in error when they cited the nursing home.
Dexter Health Care appealed the report’s findings to the state, and the state did modify some of the wording on the statement of deficiencies — it withdrew a sentence that said the resident died during the event and another that said two certified nursing assistants on duty were not CPR-certified. It also revised the number of nights it found without any CPR coverage from a higher number down to just one of 25 nights, July 4.
But, the main thrust of the report — that the nursing home had violated federal regulations and would be fined $5,850 — remained intact. The federal Centers for Medicare and Medicaid Services reviewed and upheld the state’s findings.
In the wake of the state inspection, things have changed at Dexter Health Care.
While it disagreed with the state findings, the nursing home did respond to the report by making changes.
“We met or exceeded the recommended corrective plan of action. We were pleased that when investigators revisited, they found Dexter to be in compliance and ruled that any deficiencies were properly corrected,” according to the statement.
Edelman said elderly residents all across the nation suffer the consequences when nursing homes fail to take care of them properly.
However, she said, the fault rarely lies with the staff members themselves.
“They’re working in difficult situations,” she said. “In many places, there aren’t enough of them to do the work.”
Instead, she said, advocates for better care focus on management decisions, particularly staffing levels, that are often made with too much of an emphasis on cost-cutting. It’s not enough to have the right policies on the books, she said. Adequate numbers of staff with proper training have to be in place to carry those policies out.